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Asian Pac J Trop Biomed 2016; 6(2): 164–172164

Asian Pacific Journal of Tropical Biomedicine

journal homepage: www.elsevier.com/locate/apjtb

Original article http://dx.doi.org/10.1016/j.apjtb.2015.11.002

*Corresponding author: Kirill Sergeevich Golokhvast, Scientific Educational Center of Nanotechnology, Far Eastern Fvostok, Russia.

Tel: +7 914 690 7603Fax: +7 423 222 6451E-mail: droopy@mail.ruThe study protocol was performed according to the Helsinki declaration and approved by Ethic Committee of the Am

Informed written consent was obtained from Amur Regional Hospital with sign of all patients.Peer review under responsibility of Hainan Medical University. The journal implements double-blind peer review practic

members.

2221-1691/Copyright © 2016 Hainan Medical University. Production and hosting by Elsevier B.V. This is an open accesscreativecommons.org/licenses/by-nc-nd/4.0/).

Step-by-step external fixation of unstable pelvis with separate anterior and posteriormodules

Ivan Viktorovich Borozda1, Nikolay Alexandrovich Ganzhurov1, Alexander Alexandrovich Kapustyansky1,1 2*

Roman Valerievich Nikolaev , Kirill Sergeevich Golokhvast

1Department of Traumatology and Orthopedics, Amur State Medical Academy, 95 Gorky Street, Blagoveshchensk, Russia

2Scientific Educational Centre of Nanotechnology, Far Eastern Federal University, 10 Pushkinskaya Street, Vladivostok, Russia

ARTICLE INFO

Article history:Received 26 Aug 2015Received in revised form 29 Sep, 2ndrevised form 8 Oct 2015Accepted 12 Nov 2015Available online 10 Dec 2015

Keywords:Unstable pelvic injuriesExternal fixationSeparate step-by-step repositionTraumatology

ABSTRACT

Objective: To evaluate the treatment outcomes of patients with pelvic ring injury byapplying step-by-step external pelvic fixation and circular external fixation device.Methods: A total of 28 patients suffering from disintegrated pelvic ring injury are involvedin the study. Fourteen patients (the treatment group) underwent step-by-step external pelvicfixation by applying anterior (anti-shock) and posterior modules. For the rest 14 patients(the experimental group), the osteosynthesis were conducted bymeans of a circular externalfixation device. The long-term outcomes were evaluated in a year after the injury.Results: The residual deformity of 5 (4–7) mm was observed in 10 patients (71.4%) fromthe experimental group. In the treatment group, the residual deformity was evident only in 4(28.6%) cases being 2.5 (2–3) mm (P = 0.000319) on the average. The functional result(according to the Majeed scale) was statistically better in the treatment group(P = 0.000319). Nine (64.3%) and five (35.7%) patients in treatment group showedexcellent and positive results, respectively. The excellent result was demonstrated by 3patients (21.4%) of the experimental group, the positive outcomes were observed in 6 cases(42.9%) and the unsatisfactory one was displayed by 1 patient (7.1%) of the same group.Conclusions: The modular approach applied is the advantage of the transosseousosteosynthesis allowing for a separate anterior (anti-shock) fixation and final posteriorreposition of the pelvic ring preceded by the stabilization of vital functions. The abovementioned method gives an opportunity to increase the amount of techniques applied forthe pelvic external fixation in polytrauma cases.

1. Introduction

In accordance with the national and foreign researchers, therate of pelvic fractures in cases of polytrauma ranges from 20%to 52% [1–5]. In addition, pelvic ring discontinuity anddestabilization caused by bone fractures and joint disruptionsare observed in 80% cases of pelvic injuries [6–10]. Despitethe success having been achieved in the polytraumacomprehensive treatment over the last 25 years, the lethalityrate in cases of severe multisystem and multiple pelvic injuriesstill varies from 35% to 70% [11,12].

Multisystem and multiple pelvic injuries are observed in upto 90% cases being accompanied with traumatic shock, thus,aggravating the severity of a patient's condition. That is why lifesaving actions shall dominate during the first hour after theinjury [13–18]. After the stabilization, the pelvic ring injury shallbe treated as a long-standing trauma requiring a special subse-quent treatment approach [19–21].

The time limits of final pelvic osteosynthesis directly dependon the efficiency of anti-shock treatment conducted in the acutetraumatic disease period. Hence, the search of new emergency

ederal University, 10 Pushkinskaya Street, Vladi-

ur State Medical Academy (N�3 OT 26.10.2011).

ed by specially invited international editorial board

article under the CC BY-NC-ND license (http://

Ivan Viktorovich Borozda et al./Asian Pac J Trop Biomed 2016; 6(2): 164–172 165

surgical stabilization techniques to be applied in cases of un-stable pelvic ring injuries are currently important [22–24].

The present study aimed to develop highly effective trans-osseous osteosynthesis techniques to achieve better treatmentoutcomes while treating unstable pelvic fractures.

2. Materials and methods

Treatment outcomes of 28 patients with unstable pelvic in-juries caused by polytrauma and admitted to Amur RegionalClinical Hospital, Clinical Hospital of Yakutsk Medial Instituteand Blagoveshchensk City Clinical Hospital in 2009–2013 wereincluded in the present study.

As per the injury mode, the pelvic fractures were high-energyand closed. All the patients suffered from multisystem andmultiple injuries [injury severity score (ISS) > 17]. Twelvepatients were diagnosed with cranium-brain trauma, 17 onessuffered from visceral injuries and skull bone fractures ofdifferent locations were observed in 20 cases. The most patients(n = 19) were taken to clinical hospitals during 24 h – 2 weeksafter the injury, and 5 patients were admitted to hospital in 3 hafter the injury and the rest injured (4) were hospitalized morethan 2 weeks after the trauma.

The injured people were divided into two groups with 14patients in each. The patients having undergone step-by-step

Table 1

Osteosynthesis algorithm of unstable pelvic injuries [C type according to AO

Instabilitytype

Posterior pelvic injury type Types of posteriorosteosynthesis

Unilateral injuries (C1 and C2 types according to AO/ASIF classification)“Openbook”,“closedbook”

I. Denis IIIII. Denis IIIII. Denis IIV. Sacroiliac joint disruptionV. Splintered posterior spinefractureVI. Vertical flank bone fracture

External fixation dreparative plateExternal fixation dreparative plate, cscrews, tie rodsReparative plate*Reparative plate, cscrews

“Crumpledbook”

I. Denis IIIII. Denis IIIII. Denis IIV. Sacroiliac joint disruptionV. Splintered posterior spinefractureVI. Vertical flank bone fracture

External fixation dreparative plateExternal fixation dreparative plate, cscrews, tie rodsReparative plate*Reparative plate, cscrews

Bilateral injury (C3 type according to AO/ASIF classification)“Openbook”,“closedbook”

I. Denis IIIII. Denis IIIII. Denis IIV. Sacroiliac joint disruptionV. Splintered posterior spinefractureVI. Vertical flank bone fracture

External fixation dreparative plateExternal fixation dreparative plate***

screws, tie rodsReparative plate**

Reparative plate**

screws“Crumpledbook”

I. Denis IIIII. Denis IIIII. Denis IIV. Sacroiliac joint disruptionV. Splintered posterior spinefractureVI. Vertical flank bone fracture

External fixation dreparative plate***

External fixation dreparative plate***

screws, tie rodsReparative plate**

Reparative plate**

screws

*: Invariable indications for a surgical intervention (selection method); **: Tpelvic ring areas followed by the stabilization of posterior pelvic areas; ***: Bin massa lateralis ossis sacri or by a reparative plate with stabilizing screws

external fixation of unstable pelvis by applying separate ante-rior (anti-shock) and posterior modules were included into thetreatment group. The circular external fixation devices wereapplied for conducting osteosynthesis in the experimental group.The classical procedures developed in Ural Scientific ResearchInstitute of Traumatology and Orthopedics named after VDChaklin were followed while carrying out the surgical inter-vention [25]. In accordance with the procedures, the cut in pinsinserted into the pelvic bones shall be fastened to the externalsupport around the pelvic ring.

The groups were compared according to the basic parametersof gender, age, trauma mode and severity and patients' conditionafter admission (P> 0.5).

Male patients prevailed among the patients: 8 (57.7%) menwere presented in the treatment group, and 9 (64.3%) ones wereincluded in the experimental group. The most injured patientswere of a productive age being 21–50 years old. In compliancewith the Association of Osteosynthesis (AO) fracture classifi-cation [21], all the patients suffered from unstable injuriesaccompanied with the discontinuity in the anterior andposterior areas and vertical dislocation (C type).

In all cases, the consent to the surgical intervention wasobtained either from patients or from their relatives.

When choosing an osteosynthesis method the tactical algo-rithm was used subject to pelvic ring injury type: 1) the direction

/Association for the Study of Internal Fixation (ASIF)].

pelvic area Anterior pelvic injurytype

Types of anterior pelvic areaosteosynthesis

evice,

evice,ancellous

ancellous

Pubic articulationdisruption“Butterfly” fractureTheir combination

Pubic plate, external fixationdevicePubic plate, external fixationdeviceJ-type plate, external fixationdevice

evice,

evice,ancellous

ancellous

Pubic articulationdisruption“Butterfly” fractureTheir combination

External fixation device*with the diamond-shapedrepositioning knot as per theprocedure developed byRunkov** [26]

evice***,

evice***,, cancellous

*

*, cancellous

Pubic articulationdisruption“Butterfly” fractureTheir combination

Pubic plate, external fixationdeviceExternal fixation device,reparative plateJ-type plate, external fixationdevice

evice***,

evice***,, cancellous

*

*, cancellous

Pubic articulationdisruption“Butterfly” fractureTheir combination

External fixation device*

with the diamond-shapedrepositioning knot as per theprocedure developed byRunkov [26]

he first stage includes the correction of diagonal deformity of anterioroth injured sacroiliac joints are synthesized by the external fixation devicein masa lateralis ossis sacri.

Figure 2. Transosseous module for the reposition and fixation of posteriorpelvic areas (posterior module).1: Cut in cone-shaped nails of cervical type; 2: Holders with three plain andone front threaded holes; 3: Threaded nails; 4: Struts with holes; 5: Holderswith one pierced hole and threaded shank; 6: Adjusting nuts.

Ivan Viktorovich Borozda et al./Asian Pac J Trop Biomed 2016; 6(2): 164–172166

of the pelvic parts dislocation (“open book”, “close book” and“crumpled book” types); 2) unilateral or bilateral injury; 3) thetype of interior and posterior pelvic semi-ring injury (joint dis-ruptions or fractures) (Table 1) [26].

Thus, in case of the external-rotational (and at the sametime vertical) pelvic dislocation preceded by unilateral unsta-ble pelvic injury of the “open book” type and the simultaneoussacral bone trauma of Denis III or Denis II types, the osteo-synthesis of the anterior pelvic area shall be accomplishedeither with the application of an external fixation device orwith a reparative plate, while the external fixation device withposterior module or a reparative plate shall be applied for theposterior pelvic area. In case of a sacral bone injury of Denis Itype, the osteosynthesis of posterior pelvic area can beaccomplished by means of a cannulated screw as injuries ofthe type bear no risk of intra-foraminal constriction injury tothe sacral plexus roots.

The treatment group patients underwent two-stage curing(step-by-step strategy) in compliance with the transosseousosteosynthesis type elaborated by our team for treating unstablepelvic injuries [27]. Emergency stabilization applying the anterior(anti-shock) treatment module was conducted during the firststage (30 min–2 h after the patient's admission to hospital)[28]. After the vital functions have been restored, the pelvicosteosynthesis with transosseous posterior module wasimmediately accomplished aimed at reaching final repositionand reliable stabilization of fragments [29].

The devices and treatment modalities having been developedby our team differ from the widely known circular externalfixation devices (Figures 1 and 2).

The posterior pelvic final reposition and fixation during theconsolidation period are possible due to the posterior module.The precondition of the construction application is the continuityof posterior flank bones areas (spines) used for fixing the pins.At that, the latter shall not penetrate into the sacroiliac jointcavity, thus, making this device different from the most tradi-tional ones for osteosynthesis.

The construction is made of the standard set of Ilizarov framedetails being cost effective and more affordable as part of thecompulsory health insurance program [30].

Posterior module osteosynthesis is accomplished in thelateral recumbent position on the stable pelvic side with theexternal frame of the posterior external fixation device modulebeing put between the surgical table support bearings, thus,

Figure 1. Anti-shock external pelvic fixation device (anterior module).

allowing for carrying out the required manipulations withoutany obstacles. Moreover, the external frame of the posteriormodule can be easily fixed to the surgical table for making anadditional support during the unstable pelvic ring reposition(for lowering).

Roentgenometry and the evaluation of average residual pel-vic part dislocation index (Нav) offered by the Ural ScientificResearch Institute of Traumatology and Orthopedics [13] and therating scale of functional treatment outcomes as per Majeedscale [31] were used to analyze the long-term treatment resultsin a year after the injury.

The anatomical outcome was considered positive if theposterior and anterior pelvic residual dislocation was less than10 mm and 15 mm, respectively, pelvis joint asymmetry wasbelow 10 mm and the pathological mobility of pelvic parts(Нav < 11.7 mm) was absent; the result was considered satis-factory if the posterior and anterior pelvic dislocation was 10–19 mm and 15–29 mm correspondingly, pelvis joint asymmetrywas 10–19 mm, and the pathological pelvic mobility was lessthan 5 mm (Нav < 22.3 mm); the outcome was considered un-satisfactory if the posterior and anterior pelvic dislocationexceeded 20 mm and 30 mm correspondingly, the pelvis jointasymmetry was more than 20 mm regardless the pathologicalpelvic mobility (Нav < 23.3 mm).

The software package Statistica Version 8.0 was applied forprocessing the statistical data. The accuracy of the averagevalues was evaluated with the help of Wilcoxon signed-ranktest (for the dependent samples) and Mann–Whitney U test(for the independent samples). Median center and interquartilerange (25%; 75%) were figured out to estimate the samplevalues. The distinctions with P < 0.05 were regarded statisti-cally significant.

3. Results

After the treatment completion, the residual displacement of5.5 mm was revealed in 10 patients (71.4%) from the experi-mental group having undergone surgical intervention byapplying the circular external fixation device. At the same time

Ivan Viktorovich Borozda et al./Asian Pac J Trop Biomed 2016; 6(2): 164–172 167

the residual deformation of 2.5 mm (P = 0.0039) was observedin 4 patients (28.6%) of the treatment group having beenaccomplished osteosynthesis by means of the external fixationdevice with separate modules. Thus, the anatomical treatmentoutcome reached by applying the offered techniques was ver-ifiably better than the result obtained after using the circularexternal fixation device.

The functional treatment outcome was also better in thetreatment group (Table 2). Only excellent and positive resultswere observed in the treatment group and the median value was90 scores. As to the experimental group, the rate of satisfactoryand unsatisfactory results was in 35.7% patients while theaverage value was 72 (P = 0.000319).

Table 2

Functional treatment outcomes as per Majeed scale.

Treatmentoutcomes

Treatment group Experimental group

No. of patients % No. of patients %

Excellent 9 64.3 3 21.4Positive 5 35.7 6 42.9Satisfactory – – 4 28.6Unsatisfactory – – 1 7.1Average value,Median grades(25%; 75%)

90 (83–97) 72 (58–74)P = 0.000319

P: Statistical significance of the group indicators.

In our opinion, the distinguishing biomechanical propertiesare the reason for the better anatomical and functional treat-ment outcomes reached in cases when the above mentionedtechniques were applied as against the cases which used thecircular external fixation device. A separate reposition knotformed in the posterior pelvic area is based on two (instead ofone) cut in pins (unlike the circular external fixation device),encouraging more localized efforts at the site of sacroiliac jointcavity fracture or disruption and assuring a more stable fixa-tion in the long run. The use of the circular fixation deviceusually leads to redislocation affecting the overall anatomicaloutcome.

As to the functional outcome, it is a more subjective indexnot always fully conforming to the anatomical changes. Still, thetwo-module external fixation device is more convenient for thepatients whose attitude towards it is more positive than to thecircular one. Here are some case studies.

3.1. First case

A male patient of 26 year old was admitted to the ClinicalHospital of Yakutsk Medial Institute in 2 h after the injurycaused by a car accident and being in the extremely critical

Figure 3. Examination results of a patient (26 years old) after admission to hoX-ray picture of pelvis in frontal view (a) and caudal view (b); (c): CT image.

condition. Systolic blood pressure was less than 80 mmHg;heart rate was 120 per minute; pulse was fine and scarcelyperceptible. In the course of anti-shock treatment, the patientwas examined in the Emergency and Anesthesia Department.The patient was diagnosed with closed left-side pubic archfracture and right-side massa lateralis ossis sacri fracture(Figure 3a, b and c).

The patient had closed cranio-cerebral injury-mild braincontusion and subarachnoidal hemorrhage, and traumatic shockof Level III (ISS = 29). Right-side transforaminal sacral bonefracture was revealed after CT imaging. The anterior (anti-shock) module was used for the emergency pelvic stabilizationand the posterior module was applied for conducting thescheduled osteosynthesis (Figure 4) in 10 days. The dislocationswere removed and the pelvic ring shape was restored in theanterior and posterior areas. No neurological disorders wererevealed. The short-term treatment outcomes are displayed onFigure 4. Rehabilitation was started in 24 h after the surgicalintervention. On the sixth day, the patient was taught to walkwith crutches. The device was removed in 8 weeks.

The patient got back to work in 12 weeks after the injury. Thetreatment outcome is considered positive.

Applying the elaborated method for treating patients withpolytrauma during the acute traumatic disease period allows forsuppressing hemorrhage and fixing pelvic bone fragments inorder to avoid further trauma. At a later date, the abovementioned technique prevents from the forced hypodynamia andthe associated complications, thus, improving the motoringconditions and life quality.

3.2. Second case

Sitting on a passenger seat, a 42 year old woman got aninjury in a car accident caused by the frontal crash of two motorcars. The woman was squeezed in crush, some body parts weredeformed and she lost consciousness at the moment of trauma.

An ambulance team provided her with the first aid. Cramer'ssplints were applied for the shank and forearm immobilization,and pelvis immobilization was accomplished as per Volkovichmethod; narcotic analgesics were administered, and anti-shocksolutions were infused in the peripheral veins. The patient wasadmitted to Murmansk City Hospital in an hour after the injurybeing in the extremely critical condition: systolic blood pressure60 mmHg, coma I. Left-side transforaminal splintered sacralbone fracture and pubic articulation disruption with the verticalleft-side pelvic instability were confirmed after CT imaging(Figure 5). The treatment procedures were carried out in thepatient's room within the Emergency and Anesthesia Depart-ment including anti-shock infusion in 2 central veins and

spital.

Figure 4. The 7th day after posterior module installation.

Figure 5. 3D CT imaging in a hour after the injury.

Figure 6. 3D CT imaging of pelvis made after anterior fixation.

Figure 7. X-ray picture of pelvis. The combination of external fixationdevice and screw stabilization of the sacroiliac joint.

Ivan Viktorovich Borozda et al./Asian Pac J Trop Biomed 2016; 6(2): 164–172168

skeletal extension applied for stabilizing the injured extremitysegments.

Clinical diagnosis for the patients included car accidentpolytrauma: unstable pelvic injury (C type); the primary opendislocation-fracture of right ankle bone; closed right-side splin-tered displaced fracture of radial bone distal epiphyseal cartilage;brain contusion of low severity level; coma of I level andtraumatic shock of III level (ISS = 34).

The stabilization of arterial blood pressure (110/80 mmHg)was followed by the pelvic fixation applying anti-shock pelvisbandage. In 8 h after hospitalization the patient was admitted toAmur Regional Clinical Hospital in Blagoveshchensk by the airmedical helicopter being accompanied by a doctor. The flighttime lasted for 1.5 h.

The subsequent treatment was provided in the Emergencyand Anesthesia Department of the Amur Regional ClinicalHospital. In the course of anti-shock therapy, the external fixa-tion device with the anterior module was used to fix the pelvicfragments under the general endotracheal anesthesia 30 min afteradmission (Figure 6). The right forearm was fixed with a plasterbar and the fenestrated plaster cast was used to fix the left shank.The wound cleaning was performed.

Pelvic osteosynthesis applying the external fixation devicewith posterior module was conducted in 10 days after the injury.At the same time the shank injury necrectomy was performedalong with the osteosynthesis of left ankle joint applying theexternal fixation device and the osteosynthesis of right forearmwas accomplished applying the Ilizarov frame. Rehabilitationexercises with the gradual increase of motion range in the

unfixed joints and the training of walking skills were carried outduring the postoperative period.

Control CT and clinical test preceded the removal of theexternal fixation device under intravenous anesthesia in 75 daysafter the surgical intervention.

Temporary incapacity lasted for 8 months. The long-termtreatment outcome (in a year) was evaluated as a positiveone.

If the situation so requires, the step-by-step application ofmodule of transosseous constructions can be combined with theexternal fixation of posterior pelvic areas preceded by theremoval of rough dislocations in the external fixation device(Figure 7).

The stabilization of posterior pelvic areas applying the rele-vant module allows for its combination with the externalosteosynthesis of acetabulum and anterior pelvic ring areas.

3.3. Third case

An ambulance team delivered a female patient of 18 yearsold to the injure care centre of II level in 30 min after injurybeing the result of a vehicle accident.

The following diagnosis was set after admission: splinteredfracture of right flank bone wing and shaft, high double columnfracture of right acetabulum, bilateral fracture of pubic andsciatic bones, ileum mesenterium disruption and hemoper-itoneum, with traumatic shock of III level (ISS = 41).

Ivan Viktorovich Borozda et al./Asian Pac J Trop Biomed 2016; 6(2): 164–172 169

Anti-shock therapy was combined with emergency laparot-omy. Conservative therapy including skeletal extension was notefficient. In 7 days, the patient was admitted to the injury carecentre of I level (Amur Regional Clinical Hospital in Blago-veshchensk). CT imaging was performed after admission(Figure 8).

Figure 9. CT imaging after osteosynthesis.

Figure 8. 3D CT imaging of pelvis in frontal (a) and caudal (b) view.

Figure 10. 3D CT imaging of pelvis in frontal (a) and caudal (b) view in 8weeks after the removal of fixation device.

A scheduled surgical intervention was carried out on the 9thday after the injury for accomplishing osteosynthesis applying aring-supported external fixation device of 3/4 of the thighcircumference and traction-closed continuous reposition of ac-etabulum (Figure 9).

Rehabilitation was started on the 2nd day after the surgery.On the 10th day, the patient was taught to walk with crutches.The device was removed in 9 weeks, control CT was made in8 weeks after the device removal (Figure 10).

The emerged adhesive small bowel obstruction required onemore surgical intervention. The patient continued her studies in20 weeks after the injury. The treatment result was evaluated aspositive.

3.4. Fourth case

A 17-year-old female patient got a polytrauma caused by thefall from a 4-storey building. The first aid was provided by anambulance team.

The patient was taken to the waiting room of the AmurRegional Children's Clinical Hospital in 30 min after the injury.

Ivan Viktorovich Borozda et al./Asian Pac J Trop Biomed 2016; 6(2): 164–172170

Her condition was extremely critical: systolic blood pressurewas 70 mmHg and coma of I level.

Diagnosis of the patient included catatrauma: closed poly-focal pelvic and left-side acetabulum fracture with the iliacdislocation of left thigh; ruptured spleen and hemoperitoneum;brain contusion of low severity level; coma of I level andtraumatic shock of III level (ISS = 38).

In the course of anti-shock treatment, the patient wasexamined and underwent an urgent surgical intervention.

The pelvis X-ray picture displayed the fracture of anteriorcolumn and posterior acetabulum with left thigh dislocation(Figure 11a). Laparotomy, reinfusion, splenectomy, closedreduction of femoral head and pelvis osteosynthesis by applyinganterior (anti-shock) module and extension beyond the left thighwere applied. The X-ray picture of pelvis after external devicefixation with anterior frame for pelvis and thigh was shown inFigure 11b.

Figure 11. X-ray picture of pelvis before (a) and after (b) external devicefixation with anterior frame for pelvis and thigh.

Figure 12. The patient in the course of physical therapy on the 5th dayafter surgery.

Figure 13. The same patient. Functional treatment outcome in an year afterthe injury.

External acetabulum osteosynthesis applying screws wasaccomplished in 10 days. The external fixation was prolonged(Figure 12).

The external fixation device was removed in 6 weeks and therehabilitation treatment course was carried out. A partial load onthe left leg was permitted in 3 months after the surgery, and acomplete load was allowed in 6 months.

Temporary incapacity lasted for 8 months. The long-termtreatment outcome was evaluated in a year (Figure 13) andregarded as positive.

4. Discussion

Transosseous osteosynthesis of unstable pelvic injury allowsfor a separate step-by-step reposition of the anterior and poste-rior pelvic semi-rings by applying two separate transosseousmodules which assures low-traumatic reposition and the stabi-lization of pelvic fragments by means of reducing weight ofexternal fixation device [28].

Ivan Viktorovich Borozda et al./Asian Pac J Trop Biomed 2016; 6(2): 164–172 171

The application of two pins, as against one, inserted into theposterior spines of flank bones excludes rotation and provides anopportunity to use the uninjured pelvic part as a reliable supportfor reposition and fixation. The above mentioned technique canbe applied upon condition that the posterior areas of flank bones(the places of pin insertion) are either uninjured or unilateralinjured. In such a situation, there is no need to use a massiveexternal frame surrounding a patient's body and entailingconsiderable inconveniences as against the circular externalfixation device upgrading the quality of patients' lives during thetreatment period [29,30].

The application of the uninjured pelvic ring as a locatingsupport (the missing external frame segment) serves as thebiomechanical point for applying separate transosseous modulesas there is no sense to treat the uninjured pelvic ring area with anadditional external support.

Separate reposition of posterior areas is highly efficientespecially if applied during a two-week period after the injury. Atthe same time, in clinical cases when more than 2–3 weekspassed after the injury and the time for the appropriate single-stepreposition was lost, the posterior and anterior modules of theoffered external fixation device can be combined, thus, switchingto the gradual reposition by applying a circular frame device andfollowing the method elaborated in the VD Chaklin Ural Sci-entific Research Institute of Traumatology and Orthopedics.

The offered step-by-step treatment (in the acute period) oftraumatic disease caused by polytrauma provides an oppor-tunity to suppress hemorrhage and avoid the second hitbrought about by a massive surgical intervention. In the longerterm, it prevents from the forced hypodynamia and associatedcomplications.

The module approach of the external fixation device allowsfor gradual addition of posterior module to an anterior one(preceded by the stabilization of vital functions) and the finalreposition of both anterior and posterior pelvic areas.

Clinical conditions (wounds and abrasions, traumatic softtissue detachment, bedsores, burns and the danger of constric-tion injury of lumbar plexus nerve roots caused by traumas ofDenis II and III types) requiring external fixation of posteriorpelvic areas are the invariable indications for applying the abovementioned procedure.

In case of old and long-term unfixed injuries or the step-by-step correction of fixed deformities, the transformation of themodule of circular external fixation device allows for the gradualstabilization and reposition of pelvic ring fragments.

The stabilization of posterior pelvic areas by applying therelevant module provides an opportunity to combine it with theexternal osteosynthesis of acetabulum and anterior pelvic ringareas as well as to apply external fixation of posterior pelvicareas (if necessary) having removed rough dislocations in theexternal fixation device.

The described osteosynthesis techniques serve as a reliableand low-cost alternative for the existing external (two stage)methods and for osteosynthesis accomplished by means of thecircular external fixation device. It also increases the amount ofmetal constructions that may be used for curing patients sufferingfrom the isolated, multisystem and multiple pelvic injuries [29].

Conflict of interest statement

We declare that we have no conflict of interest.

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